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31 WARREN ST - BUILDING INSPECTION (2) p � The Commonwealth of Massachusetts CITY Board of Building Regulations and Standards J� Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM 7 Revised Junnwy Building Permit cation To Construct, Repair, Renovate Or Demolish a ?, 1008 ne-or Two-Family Dwelling This Sectionfic5FOfficial Use Only Building Permit umb Date Applied: 1 ` Signature: Buil4ihgCorgmis.i n 91pector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Pro arty Address: 1.2 Assessors Map& Parcel Numbers I.1a Is this an accepted street?yeses no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 7_omng District Proposed Use Lot Area(sq R) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required I Provided Required Provided Required Provided r 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Zone: _ Outside Flood Zone? Municipal K1 On site disposal system ❑ �- Private❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of c rd: / ��.�� /I�a TIC/� ti- m U2p� Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Jq Existing Building vk Owner-Occupied K Repairs(s) ❑ Alteration(s) ❑ Addition Ic Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work'-: S'/Aj S f / A/ 7 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ O I. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical IfIVAC) $ 'U List: 5. Mechanical (Fire $ O Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: S ��oo� G 11 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �113 { /0 %15 /�` ��...��� License Number lispi nun U to Name�o�f C�SI= I]older G U -/Z ¢� r List CSL Type(see below) Address .I.. Description IJ Unrestricted(up to 35,000 Cu. PIJ R Restricted I&2 Family Dwelling Signature(� pp M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) `j 3 -;7 e7 v lIC Company Name or HIC Registrant Name Registration Number Address G 'Expiration Date Signat a Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT�O/RC CONTRACTOR APPLIES �FJO/R�BUILDING PERMIT I, z//f3'7�F'!/�/v✓ �/ r r! U�Pr "7 as Owner of the subject property hereby authorize �� �7 0 CJ� T( to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Dale S�E/C�TIIO/N�7b: C N(EW OR AUU7THH,{O�RIZED AGENT DECLARATION Ci - / /'t cla "/ , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing applicaiion are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authdrized Agent Date (Signed under the pains and penalties of er'u NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program), will toot have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 110.RS, respectively. 2. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) 'r� (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) FJ Habitable room count 0 Number of fireplaces (7) Number of bedrooms £7 Number of bathrooms 0 Number of half/baths Type of heating system CD Number of decks/porches OlViT— Type of cooling system O Enclosed _Open 3. "Total Project Square Footage"may be Substituted for"Total Project Cost" „ ,Q Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT. 311 FAX (978) 740-0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction 0 Moving ❑ Reconstruction '1�' Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other work as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntir Address of Property- 11 Warren Street Name of Record Owner: Matthew Murphy & Sarah Morrill Description of Work Proposed: Construction qfa I story, wood glass enclosed, 4 season porch addition per plans and sketches submitted, painted white. Windows to be Brosco wood true divided light, single glaze, clear glass. Copper roof, white aluminum gutter. Handrail to match handrail on East elevation. Installation of copper, 3 rail snow.fence. Dated : June 7 2010 SALE ICA CO MISSION By: The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. TI[IS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. r -- Q Z 0 N N 7 � H O V EXISTI% F z Q EYbiINS E%15iIN5 Basement z Kitchen Dining Rm. W R FIAT PILASTER AT R �' (QJJ EX15T.A .Y �� CORNER MATCH _ jI 3•HT.BLLE Ti M4L S2 W "5TIN5 AT PGRTIIq -0 y r LAP AT AREAHAY NPLL N m 0 oE O `Yl'.VJ ul 1/4 RDIMU WALL EXI5TIW BV.XI BASE BRICK O a P B Vest. AT EXIT WALL aar A B Areaway e•woE coNc. g 1_ (UMRY nlE 1 tq TIE-IN FOOTIN W ¢ ' O ' � ' •:'a t - l IMERMFDIATE P.T.4X41 1 ^ r Q V arc' v.3 a Porch I B rc oP R�� �ow '�y o CO)_ _ z' z r YCtlV Ft.cg2 VA-4 -� S /Ai /A-4 I ABV. B A A B M "+ f 3 T �OONT I Nt.P�TING'I I TYp_ IN 9 4-ELW.6RACE1 I Landing o R o o u� wllx METAL R41LII15 TO h F�ASGIA PPUV2 IMTGN E%ISTIN6 - PORTICO (/JMPOiITE I-3 4'-3' 13'-10' ` DFLKIIl9 ON P.. - - YYA'9 STAIR Gl-.IE• m P.t.9X4 PoST TO MDERSIpE OF ROOF � lI/3" a'-l" FRAMIWS 5E£STRWi.TMAANO SK IT S TB BEAMSATRTUIffTHi YV BPLV. PGA FpJNOAnON ANp FRPf11N5 INFO a PosT BASE.AN INTO COII'.R2TF a 5t" 1 Iz-T,/r' - R- Po1}mAnoN PIERSI-TYP. U 1112 0 1 Irz^ K W m Areaway/ Foundation Plan a a S E 5T T.IbTES AUI SKETC 5 �3M'=1'b• • En FOR FC ATION AW W 11%INFO w r Porc Floor an 2 SCALE.�•.I'b• W= w � o CO N CO W � W S d' � M I ---------- Eli. CD FM 7F-7 3 M F 4 m rA I=I17 0 hlyP pl P PH 19 21 RAN '03 FE-11 MURPHY RESIDENCE PORCH ADDITION SCHEMATIC DESIGN NOT FOR CONSTRUCTION 31 WARREN STREET,SALEM,MA SCALE:AS NOTED DATE: 1027.2010 / ;-!IT ;•-- ) } - �L J. I = I ± � \R ® ! §22§ § § ( / � \\ ( 22 . �. . I � I eRPH vRES -POR CH ADDITION SCHEMATIC DESa-x FOR 2NST nna em�Nssmm �eAS_D �: ,_ Y s B 6' P-6 3H•H- � i -1� yy y yy y VIF. `° o� v o dd €d d gtl Fm'°"° p8p dim FIL FIr n Mi¶o pggggg � O Ny,-� I J � lk C If-- - 1 Q 0 3M. QY__—-____ .-------_— ® L Ng AS Tq Q 73 ------ - —= lU- - p - ---- ------- - --- o�out - � _Ip I MURPHY RESIDENCE-PORCH ADDITION SCHEMATIC DESIGN-NOT FOR CONSTRUCTION r� 31 WARREN STREET,SALEM,MA SCALE:AS NOTED DATE: 10.27.2010 `�� WINDOW SCHEDULE Q HMM£IAF-BFLIBJ FPM WOXO UiNLHE-.B SI51 w,wrcas ro w�erE nErs1 c O N WIN RU64D P 0 MODELI HD.MT. TYPE SIZE(W)x(H) HEAD JAMB SILL NOTES fAFFJ � � Q T 6'-0V4• DA 2'-10 VB'xSA' - - - - f W U) < © 0 6'-1 V4' OK l Y'-51 %5'-I QP - B'd' PYNIM6 � Q - b'A' 1pM•i0w _ - _ _ LL ROOM FINISH SCHEDULE z PLILB' .FJN.`dE`2 lt4LLFw5 mu%RW'.HES <�< FI- 61MRRYVll BI- PNN 4-Iq'A H- E 511N5811LK LI- PAINED wxro BEMdDAPD U F3- WfLTCGJFLW % W-PNM®V4R M- PAIM®IQU' N M-PAIN w G7 W C ROOM FLOOR WALL CEILING CEILING V NAME FINISH BASE FINISH FINISH HEIGHT REMARKS Q VESiI&lE Fl 51,8] w,Y0,W5 G 9'-0♦/- - $- W fDRCH F1 BI,B] jmW2,W3j G _ U N DOOR SCHEDULE DOOR SQE DOOR FRAME HEAD JAMB SILL HARWARE REMARKS WIDTH HEIGHT TYPE TYPE SET 101 1'-B' 6'A' A 1 WM IRNCF1E 102 1'-B' b'-0' A 1 W1HiRNYfOME DOOR FRAME ELEVATION TYPES DOOR ELEVATION TYPES o uj c = g K uj w d Q m m In a � w zLu w w c A yyj WOOD EXTERIOR DOOR - 51MP50N DOOR LLI FRAME W/TRANSOM V P P.FIR DOOR W/3>56LA55 C �i a z = oR z o � 8 LL O E%ISTINS O z Basement z .. ]Xbs REMOVE EwsnN R, F�3< N `r r AT 12'OL. RER E E W P.T.2%10 LEDSER Sr 6 s W �/ RE-L5E EXISnN6 �L5 I Areaway 0 d` � �- m � �,_� 11 " I P.T.2res xoif ON siLPe ON „ I AT I2.OL. vI/ FT I/ .2U L((OO ul I� FLAT SEAM 4X 5 1 COPPER ROOFING 3'1 `knSl Ir II 1 III P.T 2' L2X FIB W 1 AT Ib'OL. L� SI �I II� II I' OOIBLE P.T.2x10 SECTIONS ,:•: h c _a .L_,I, , _ - �� -- --------- -- NllL M'llI -+ NTERMEOIATE P.T.4P053 TO + LNIDERSIGE OF ROOFX�DECK W B' UJLLNM EELOWL METAL GUTTER PPOJNO BRIM, DIM.�MP.OF 1 OF ALOITION. RELOCATE M® z OORLE P.T.2XIO RIM EO.-HIGH TIE INTO E%15TIN6 Q SE P.T.2AO TIE AM-LOW 1. -ttP.AF0.Np PERIM. Nam. 5EE STRmT.I'OTES ANO SKETOHES m 5EE ST T,ItlTES ANJ 5KETG FOR F ATIOH AW FRAMI%INFO FOR FOMPATION A4 FRAMI%I F a RENR nFloor Framing Plan (-.--,Porch Roof Plan LU 311V I'-0' W W W W C N rn W C 3 f � I i r a 0 N � O U O � U o I EwSnNs F�TSnNG I Exlsnraz ~O Kitchen Dining Rm. Basement = _ J PLAT PILASTER AT m� S FAST.AREWAY CASTER MATCH SII 9'HT,BLLESTd1E YNLL U y BFyp4 E%ISTINS AT PGRnLO 'O GAP AT ARE4V4Y WPLL LU W I ' I \ P E i' ® `YtlOD 1/4 ROIMp Y L IJ P EV5TING H 6 j F B I 445E AT EX15TI%BWGK B p I Q Vest wnu ow.r A Areaway B'wIDE corvc. (CARRY nIE �. M' TIE-IN POOTIN65 C W INTERMEDIATE P.T.4X41 I- 4 U ' —B O Porch A B _ 1Lj L � I :::`• ' FASTS TO IMDErt510E / ' y 'I_ z 2'r wwo ftau . __ oP ftaOP Dryac w ] M /A-4 -I 5 /A-4 I I/Ai Ot API 50101UEE--F H- I/ 4-_ p I E BA �I 3-T' (qNT.IB Ni.POOTING B •m 1 V. pCMIN 4-O'BLYL 6RAOELj , Landing I C I I I M I ❑ I Ir _ __� � i__ I � m j � yet � _ D D �D D NllI�ITllI - 2'-b V2 -3' IO 3W Z METAL"I-INB TO n MATCH EXISTING _ FASCIA PBOVE Q PORTICO (gIyPG51TE -3 4'-3' 13'-10' t DEGKIHS ON P.. Q VtlW STAIR SEE m PT.4X4 POST TO NIOERSIGE OF FGOF l IfS• 4'-T" FRPHINS SEE STf.11CT.TION PND S MIN&1S J,FPpRT BEAMS AT FFRIME=6PLV. Q POR FQINDATION FMJ FRAMIN5 INW Q PO-T BPBE,NCHLA INTO CONCRETE 5•-b• I 13'-T I/]' fWiIDATON PIER5-TYP. _ �I REAR U I a Areaway/ Foundation Plan a .E SEE STPLGT.tbTES PNO SKETCIffS > �� 1 � fA FOR PLT.MATION AM1D PRAMIN91l6d 3A6'•I'11' �„Lh Floor Plan LU W W U W CO W 2 Cr � m i mEll - m =4 c m � cUA € � A� gi NN\\\ i, � Kq 'F J � Aq I j P MURPHY RESIDENCE-PORCH ADDITION SCHEMATIC DESIGN-NOT FOR CONSTRUCTION 31 WARREN STREET,SALEM,MA SCALE:AS NOTED DATE: 10.27.2010 '�`J § /§ /s \! > ii.. / ! � . ` ` .• ! �I)\ SdL : ! z a - \ � 6 �� I } I f I \ AT ® !` / !J &§ ( ■ \ © � - I � I / I � I ea,RES_x-POR CH ADDITION SCHEMATIC DESa-NOT FOR c s u a e WARREN s s m MAe< D _u�_ F N S Jd 4 -7B b' 3'6 3/9'�/- 6' B' 177 I'-41R' N V.I.yF. N § Rs N O 1 I• I•.1� yy y yy yy yy z $ yy � 4 �� 6 � o� �' s d o �d $d d � d ��H� �2d s�� $ F�6�I § II AI FEi y �If L_ : f m i „ Q � 103H" d (NFIE 0 a ------------ F T ti I 1 1 I F 1 I � I PcN I �� I MURPHY RESIDENCE-PORCH ADDITION SCHEMATIC DESIGN-NOT FOR CONSTRUCTION 31 WARREN STREET,SALEM,MA SCALE:AS NOTED DATE: 10.27.2010 �� a _ � N F- r (� N G N O � C1 11� o E%5TIN5 O Z Basement z .. 6� P. RT,2X6 REMOVE E%ISTIN6 ��_ N S AT 12.OZ. RE E W P.T.2 10 LEO6CR S REAEE EX15TIW POLTs W C Areaway II G INe� ��� ' ��� 1 Lfl UP P.T.3Y65 SLO�r DN SLPE pN F� W Ilry�ill II, AT l2•DL PAR 3X 51 I.. ' FLAT II II I I'i I,`�1' VA-4 HII 1�:I1'T L�ERR�IN� D T.2X105 II Ai lb'OL. 1 SE 9LE IT.2XI0 6 �F �NTERMEO�IE P.T.1 X4� TO 1RDER5 SEE I IpL�L '' P IIN TILE OF R MIX 0' T GOLLMN E5ON METAL ELTIER ARWNO F IK OIAM.'ANOIIP_E(TYP.Of:3) OF ADDITION REI(KATE P.Np Z VQ P.T.2`(10 RIM W,-HIGH TIE IWO EXI5TIN6 Q P.T.2XIO TIE f£Nt-LON t -ttP.A O FERIM. NOTE 0 SEE 5TTQILT.Wb MO SKETLHES T SEE ST T IYIIES AND'XETLIffS 9 4 FOR FOINOATION ND F I%INFO <_ FM F ATION ANO FRAMIt151NF0 V REAR g nFloor Framing Plan Porch Roof Plan d g ,, V W W W O � W(A N C Z W S Q a WINDOW SCHEDULE Q ml wtg A�SBFLiH�FPMEAOLO LATAICbE-.BSIEN Au wroas.o FFlfi`r llEfLF sins = c MR (] MODEL# HD.HT. TYPE So IND HERO JAMB SILL NOTES ? c (AFF! QQ T 6'-'IW DR 2-10 V6'X 54' - N O O QQ 6-3' © 6-3' O LL ROOM FINISH SCHEDULE O z fld FIN'11E5 96&1 µLLL FINI51E5 CEILING FIM51ff5 Q� U FI- (LACY TILE BI- PAW w%A W- PAI T BRILK GI- PAINED 4NOD 3fADf0AFD (� N F2- HAFDVbJD FLWWN6 32- PNNI®11V4 P0.10 w1-FAIXIEDMM y YB-PAINED WP2D W L] ROOM FLOOR WALL CEIl1NG CEILING U NAME FINISH BASE FINISH FINISH HEIGHT REMARKS G V flBV.P FI 51,32 H,W,Mj 61 9'4d- - W FIFLN F2 81,92 w,H2,W3 G 9b 4/- _ V H DOOR SCHEDULE DOOR S� DOOR FRAME NERD JAMB SILL HARWARE REMARKS WIDTN HEIGXT TYPE TYPE SET 10 2'- - 6'4' A I NIIH iRNlF1E 02 S.6' 6'-6- A I _ _ _ WIH TFMYQ1f DOOR FRAME ELEVATION TYPES DOOR ELEVATION TYPES o t s W Z w c U) 9 W HOOD EXTERIOR DOOR 51Hf 50N DOOR d' W FRAME K TRANSOM E' M.FIR DOOR = W 3X5 GLP55 M !e CITY OF SM E,%1, AxSSACHLS- �_ BtiIIDLNG DEPARTN1);NT ` 120 WASHLNGTON STREET. 3m FLOOR TEL (978) 745-9595 Rim(978) 740-9846 KI\BERLEY DN.ISCOLL Ttjoh,JAS ST.PIERRE MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CO SL�lt55IONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers 4 a licant Information Pleaxe Print Le¢iblY NaMC(Busi,es&Org,nizatiamindividual):it"'�,✓�Irt Address: City/Statc/Zip: sr Phone #:!%0-�3�-��ly Are you so employer?Check the appropriate box: 'type of project(required): ❑ 4. ❑ 1 am a general contractor and 1 6. ❑New construction 1. 1 am a employe[with ustployees(full and/or part-time).' have hired the s attached sheet. t. �. ❑ Remodeling 2.J {'1 am a sole proprietor or partner—ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. Building addition No . insurance 5. ❑ We are a corporation and its to.N Electrical repairs or additions comP ( workers' required.) officers have exercised their 11.0' re airs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL Plumbing b P myself,(No workers'cutup. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.0 Olher comp.insurance required.] -Any applic:un der 0-l"'box el mud also rill out the maioo below showins their workM compemariun policy information. t 1l,wuuuon who submit this anldavil indicating they ate doing all work and It a hire outside contactor mud suhmil a new affidavit indicating such =('ammctors that cheek this box mat anabod an additional short showing the name of the subcontractors and their workers'comp.puticy infumution. I.,an employer that it provfdinir workers'compensation illsuranee jar my employees. Below/s the policy and Jab site information. ''✓ insurance Company Name: zJQL `-'� �A_�r-rr 6 /�3 / Expiration Policy U or Self.ins. Lic. U: �-+ � l)g — q Date: City/State/Zip: �-�i£/� zte d Job Site Address: am., Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). hailum to secure coverage as required under Section 25A ot•MGL c. 152 can lead to the imposition of criminal penalties of a line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to$250.00 a day against the violator. 13e advised that a copy of this statement may bo forwarded to the Office of Investiguliorut ul the DIA For insurance coverage verification. l do hereby ctrdfy r e e pains turd penoldes of perjury thin the ileformutlon provided�bove�+a irrue died c'orrecL S. 1 DatJ• �l ✓ /U P a i. 7 3 — /S/ q/Jicial ust only. Do not write in thLr area,to be completed by city or town )JJ7c1aL City orTawn: .._--- Issuing Authurity(circle uric): 1. Board of Ileallh 2. Building Department 3.Citytrusvn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Phone U• ( Information and Instructions Massachusetts Ucner:rl Laws chapter I j2 requires all employers to provide workers' compensation fi)r their employees. I'ursuaru to tilts suatune, an rmplgred is defined as"...every pcexon in the service of another under any contract of hire, apress or implied, oral or written." An e,npluyer a defined as"an individual,partnership,:association, corporation or tither legal entity,or any two or snore ,-r the foregoing engaged in aiomt enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of .m individual,patmership,association or Other legal empty,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do muintenunce,construction or repair work on such dwelling horse or on the ,,rounds or building appurtenant thereto shall nog because of such employment be deemed to be an employer." MGL chapter 152. ;125C(6) also states that "every state or local licensing agency shall withhold the Issuance or renewal of a license or.permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally, ;MGL chapter 152, §25C(7)states"Neither the commonwealth not any of its political subdivisions shall ' enter into any contract for the performance ufpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely,by checking ilia boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificatc(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and dule the affidavit. The affidavit should he returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain it workers' compensation policy,please call the Departnent at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. I'Irase be sure to fill in the permit/license number which will be used as a reference number. in addition, an applicant that mwt submit multiple penniUlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"ali locations in (city or town)."A copy of the uffidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on fit for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture t i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I llc r)I lice OI Itivestr.gallons would like to thank yOu in advance for your cooperation and should you Ila%c any yneltlons, please du not hesitate to give us a call the Dcparunent's address, tcicphona and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offlee of Investigations 600 Washington Street Boston, MA 02111 Tat. k 617-727-4900 ext 406 or 1-877-MASSAFE ;c.•:;. d 5- t;-us Fax N 617-727-7749 www.mass.gov/dia CITY OF SM E.ANI, AxsSACHUSETTS • BUILDIING DEPARTMENT 120 WASHINGTON STREET, 3'0 FLOOR TEL (978) 745-9595 FAX(978) 740.9W KI.\IBGRr 'l:Y DRISCOLL MAYOR T�iOM.1S ST.PIF.RRB DT croit.OF PI:BLIC PROPERTY/BCII.DTNG CO%LMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: Srzl.T- (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) s natur of permit a 'cant 1/A � io date a�n ��ird.x